INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 28, 2006.
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Plan of Correction
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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Staff member 2 exceeded the individual caseload ratio at 36/1.
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Plan of Correction
704.12(a)(6) ? Outpatient Caseload
Director will adjust the client caseloads between the two facility staff on 6-5-06 to ensure compliance with the standard.
Director will monitor compliance weekly beginning 6-12-06.
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705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
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Observations
The facility has moved to a new location and failed to update the written procedures for evacuation and transfer of clients and staff to a safe location.
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Plan of Correction
705.27(4)(i) ? Evacuation Plan
Director will revise the written procedures for evacuation and transfer of clients on 6-12-06 to indicate the new facility location and relocation procedures.
Director will place the revised evacuation procedure in the facility policy and procedures manual and review changes will all facility and building staff on 6-12-06.
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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
The annual audit for fiscal year ending December 31, 2004 and 2003 was completed September 9, 2005. Audits need to be completed within six months following the end of the project's fiscal year. This audit should have been completed by June 30, 2005.
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Plan of Correction
709.25(a) -Annual Audit
Director will meet with the board of directors on 6-12-06 to review the standard pertaining to the time frames for completion of the annual audit, reinforcing the due date of June 30th.
Director will secure the annual audit for fiscal year 2005 by June 30, 2006. Previous audits were completed on the CPA's time frame and we will once again reinforce the need to utilize the June 30th time frame.
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Client record number 2 did not have a consent to release information form for billing. Client record number 4 had a blank consent to release information signed by the client and the counselor. Client records numbers 1 and 2 had Federal Bureau of Prisons releases that inferred information was to be exchanged by all parties identified by the inclusion of "by and to" on the form. Also, this form did not indicate that the client was offered a copy.
The facility did share with the licensing specialist that a new form was designed by the Federal Bureau of Prisons. The specialist explained that the new form would need to eliminate the section that indicates the client's permission to "Obtain Information From", and the revocation section needs to be revised to include verbal. Also, this form needs to indicate that the client was offered a copy.
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Plan of Correction
709.28(c) - Confidentiality
Director will retrain all facility staff on 6-14-06 on the appropriate confidentiality procedures pertaining to release for billing, appropriate completion of consent forms, and utilization of the Federal Release of information form utilized at the facility. Director will provide a sample copy of an appropriately completed consent form and review the restrictions pertaining to the release of client information.
Director will follow up with Dr. Cordella Malloy of the Federal Transitional Drug Abuse Treatment Program on 6-16-06 to revise the form utilized and will monitor to ensure it meets compliance with the confidentiality standard in question.
Director will monitor compliance via regular client chart reviews during the weekly clinical staff meetings beginning on 6-21-06.
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709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Client records number 1 and 2 did not include a family medical history or a list of symptoms and illnesses in the client's medical history.
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Plan of Correction
709.91(b)(3)(i) ? Medical History
Director will retrain all facility staff on 6-12-06 on the appropriate completion of the facility's health questionnaire, within which the client medical history is collected.
Director will monitor compliance via regular client chart reviews during the weekly clinical staff meetings beginning 6-19-06.
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709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Client records 1 and 2 did not clearly define the client's length and patterns of use, substances abused, or prior treatment in the drug and alcohol use history.
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Plan of Correction
709.91(b)(3)(ii) ? Drug and Alcohol History
Director will retrain all facility staff on 6-12-06 on the appropriate completion of the facility's health questionnaire, within which the client drug and alcohol history is collected.
Director will monitor compliance via regular client chart reviews during the weekly clinical staff meetings beginning 6-19-06.
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709.93(a)(3) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(3) Record of services provided.
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Observations
Client record numbers 3 and 4 did not have a record of services.
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Plan of Correction
709.93(a)(3) ? Records of Service
Director will retrain all facility staff on 6-12-06 on the appropriate completion of the record of service form. Director will reinforce the purpose of utilizing the form and the appropriate placement of the form in the client chart.
Director will monitor compliance via regular client chart reviews during the weekly clinical staff meetings beginning 6-19-06.
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